Exposure to Infectious Exposure to Infectious Agents in Health Protection Agents in Health Protection Agency LaboratoriesAgency LaboratoriesPresented by Presented by

Frances Knight and Ian BatemanFrances Knight and Ian Bateman

HEALTH PROTECTION AGENCYHEALTH PROTECTION AGENCY

• formed April 2003

• CMO – Getting ahead of the curve

• formed from PHLS, CAMR, National Focus

• joined in 2004 by NRPB

• around 3000 staff

• 3 major centres, 79 sites

• 1500 staff work in microbiology

• Diphtheria infection in member of staff

• HPA Board requested review

• Investigate laboratory exposures to infectious agents

• Review adequacy of actions to prevent infections in staff

• Recommend improvements

• Identify issues of wider relevance

BACKGROUNDBACKGROUND

TERMS OF REFERENCETERMS OF REFERENCE

– examine laboratory acquired infections and incidents of exposure to infectious agents during laboratory work

– identify number of incidents over 2 years and the circumstances in which they arose

– review immediate and underlying causes

– review lessons learned

– review actions taken and whether they were adequate

– determine further steps to ensure this area of risk is adequately controlled

– final report for the HPA Board

– make recommendations for further action

FINDINGS (1)FINDINGS (1)

78 recorded incidents

• Hazard Group 1 (1)• Hazard Group 2 (40)• Hazard Group 3 (32)• Hazard Group 4 (2)• Not known (3)

6 LAIs (Salmonella Typhimurium, Shigella sonnei (2 cases),

Corynebacterium diphtheriae, Salmonella Agona and Neisseria

meningitidis )

Full recovery, no transmission to others

FINDINGS (2)FINDINGS (2)

• 70% - SPILLS, BREAKAGES AND LEAKS

• 13% - SHARPS

• 11% - NO MSC/GENERATION OF AEROSOLS

REVIEW OF SPECIFIC REVIEW OF SPECIFIC INCIDENTSINCIDENTS

• LAI – Corynebacterium diphtheriae

• LAI – Salmonella Agona

• Mycobacterium tuberculosis – dropped culture

• Mycobacterium tuberculosis – dropped swab

• LAI - Neisseria meningitidis

UNDERLYING CAUSESUNDERLYING CAUSES

• staffing levels

• off-site training

• competence

• communication

• immunisation status

• accommodation pressures

ACTION PLAN (1)ACTION PLAN (1)

Increased vigilance and awareness

keep biological safety high on the agenda

Communicate findings via cascade

targeting key groups

Improved risk assessment

especially resource/space

Standard arrangements

incident reporting, investigation & analysis

System for communicating lessons learned

including pan-HPA communication of HSE visit findings

Better and more consistent CL3 training

ACTION PLAN (2)ACTION PLAN (2)

review practices against HSAC, ACDP, etc

processing at wrong containment levels

create environment for open reporting

frequency of CL2 and CL3 incidents

monitor progress against action plans

share findings across microbiology + HSE